Operationalizing respectful maternity care at the ...

Jolivet et al. Reprod Health (2021) 18:194 https://doi.org/10.1186/s12978-021-01241-5

RESEARCH

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping reviewR. Rima Jolivet1* , Jewel Gausman1, Neena Kapoor1, Ana Langer1, Jigyasa Sharma1 and Katherine E. A. Semrau2,3,4

Abstract

Background: Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

Methods: Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify opera-tional definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

Results: Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on opera-tionalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

Conclusions: Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, program-ming, research, and program evaluation aimed at studying and improving RMC at the provider level.

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*Correspondence: [email protected] Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USAFull list of author information is available at the end of the article

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Page 2 of 15Jolivet et al. Reprod Health (2021) 18:194

BackgroundMaternal mortality and morbidity are widely recognized as fundamental human rights issues, and women’s right to sexual and reproductive health care—including mater-nity care—that is available, accessible, acceptable, and of high quality (AAAQ) is a central tenet of the techni-cal guidance issued by the Office of the United Nations High Commissioner for Human Rights (OHCHR) on a “Human rights-based approach to reduce preventable maternal morbidity and mortality.” [1] Moreover, the guidance states (p.3) that “Ensuring women’s sexual and reproductive health rights requires meeting standards with regard to health facilities, goods and services…” and stipulates that “respectful care for women using health services is a critical dimension of both quality and acceptability.” Yet, to date there is no consensus on evidence-based standards for Respectful Maternity Care (RMC).

A central focus of global maternal health efforts over the last decades has been to increase the number of women giving birth within health facilities, as a mecha-nism to increase skilled birth attendance [2]. As of 2019, approximately 76% of women globally delivered in a health facility [3]. However, the global push toward facility-based birth for all women in all countries has exposed health system deficiencies and brought to light the pervasive problem of mistreatment of women in the context of facility-based maternity care [4, 5]. Several qualitative and quantitative studies demonstrate a high prevalence of disrespect and mistreatment during child-birth, including verbal, physical, and sexual abuse [6–17]. Mistreatment of women and newborns during maternity care is not only a violation of their rights, but it can also

be a deterrent to current and future skilled care utiliza-tion [11, 18]. Frontline maternity care providers are most often the perpetrators of such mistreatment; however, in many settings where the majority of care is provided by nurses and midwives, they themselves are also subject to disrespectful, untenable conditions and health system deficiencies that, in turn, drive disrespectful behavior and contribute to women’s poor experiences of care [19].

Bowser and Hill’s [11] landscape review describing and categorizing disrespectful and abusive care during child-birth was seminal in increasing visibility of this topic in policy and research settings. This work informed the development of the Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns (RMC Char-ter) (2011, updated 2019) [20] and the World Health Organization statement on the prevention and elimina-tion of disrespect and abuse during facility-based child-birth (2014) [21]. A subsequent systematic review and thematic analysis of the published literature on mistreat-ment in the context of facility-based by Bohren et al. [9], corroborated the Bowser & Hill typology and added attention to health system deficiencies. Ensuring RMC is now a key feature of the WHO vision for quality of care for mothers and newborns [5], and the WHO standards for improving quality of maternal and newborn care in health facilities [22]. Categories [11], prevalence [6, 8–10, 14, 17], and to some degree drivers [18, 19] of disrespect and abuse in the context of facility-based maternity care have been explored, and rights-based frameworks have been articulated [20, 23]. However, the absence of mis-treatment in facility-based care does not in itself consti-tute RMC. While disrespect and abuse have been well defined and studied, the “positive dimension” of RMC

Plain Language Summary

Respectful care for mothers and newborns is a right and important part of ensuring that their care is high quality and acceptable to them. Just because there is no mistreatment does not mean that Respectful Maternity Care (RMC) was given. Without a clear framework for provider behaviors that reflect RMC principles, it is hard to ensure every woman and newborn gets respectful care in practice. We compared and combined two frameworks summarizing maternal and newborn rights and came out with seven categories. Then we searched for articles that mentioned provider behaviors reflecting RMC. We found 514 articles and ended up with 54 after careful review, from which we pulled the observable behaviors for providers in each category. Almost all papers mentioned actions to protect women and newborns from harm and mistreatment, to treat them with dignity and respect, and to give information and respect choices. About half of papers mentioned actions to protect privacy and to make sure every mother and newborn gets care when needed. Only 25% of papers mentioned actions to make sure all women and newborns receive equal care, and only 15% included actions to make sure women and newborns are physically free to leave facilities at will, and get care whether or not they can pay. This framework defining RMC behaviors for providers is based on data from many studies and can be useful to look at whether maternal newborn care in facilities meets these standards and to inform training and more research to improve RMC.

Keywords: Maternal health, Quality of care, Respectful maternity care, Professional guidelines, Obstetrics & gynecology, Nursing, Midwifery, Measurement


has not been as well conceptualized, defined, described, or measured to date. Evidence generation to inform defi-nitional standards for RMC is ongoing, and in an early stage of development. While examples of calls to action, programs, and approaches to RMC training are prolifer-ating [24–26], to our knowledge no synthesis of provider-level standards for RMC has been put forward.

Frontline maternity care providers, through their inti-mate interactions with women and newborns during labor and delivery, are uniquely positioned to influence women’s experience of care, both as potential perpetra-tors of disrespect and abuse or change-agents for insti-tuting RMC [11, 21]. Bowser and Hill [11] identify four provider-level mechanisms that can contribute to disre-spect and abuse in facility-based childbirth: (1) provider prejudice and discriminatory behavior against certain sub-groups of women; (2) provider distancing from cli-ents because of training that encourages social distance and normalizes disrespectful or abusive care; (3) provider demoralization because of weak health systems, human resource shortages, limited professional development opportunities; and (4) an atmosphere of disrespect and abuse between providers translating into abuse and dis-respect of patients. Intervening at the provider level to support positive changes in provider behavior, within the context of healthy clinical environments and strength-ened health systems, is therefore essential to ensure that all women have access to respectful care from competent providers. Consensus on evidence-informed provider-level operational definitions for RMC would provide a basis for such interventions.

We conducted this systematic evidence synthesis as the first part of a larger project to explore whether essen-tial elements of RMC are included in professional prac-tice standards for frontline maternity care professionals (forthcoming publication). In this first step, to develop an operational definition at of essential elements of RMC at maternity care provider-level, we reviewed the literature in two distinct, but related, phases.

MethodsFrameworks defining rights of women during childbirthWe began by reviewing seminal literature codifying, set-ting standards and guidelines, and identifying the rights of women to receive respectful care during childbirth. We focused on rights-based frameworks for two rea-sons: first and foremost, to highlight the essential rights-based dimension of RMC as per OHCHR technical guidance and secondly, because of a dearth of clinical or professional behavioral frameworks for RMC grounded in evidence. We identified seven seminal, definitional frameworks [9, 11, 20–23, 27] that outline a broad under-standing of mistreatment of women (also referred to as

disrespect and abuse) during facility-based childbirth and refer to RMC in the affirmative. Given that the objec-tive of this systematic review was to identify categories of RMC and their operational definitions, we focused on lit-erature that described RMC in the affirmative rather than describing the categories of mistreatment experienced by women during childbirth. On this basis, we narrowed the results of our review to two seminal works that both cod-ify the rights to RMC during childbirth [20, 23].

The first framework, the RMC Charter, developed by the White Ribbon Alliance based on widely recognized global and regional human rights instruments, situates maternal and newborn health rights within the broader context of human rights [20]. The original charter iden-tified seven rights of childbearing women, each corre-sponding to one of the categories of disrespect and abuse identified in the landscape review by Bowser and Hill. Of note, there was an update to the RMC Charter in 2019 that retained the original seven rights and added three more: the right of newborns to stay with their parent or guardian, the right to have their national identity rec-ognized from birth, and the right to adequate nutrition, and water, sanitation and hygiene (WASH) in facilities. For this analysis, we utilized the original RMC Charter framework because two out of three of the newly added rights must be operationalized at the health system or policy level rather than the provider-level; and the third, the non-separation of the mother-baby pair, is addressed in the original RMC Charter.

The second framework from Khosla and colleagues [23] similarly mapped international human rights standards from a scoping review of human rights instruments to the corresponding categories of mistreatment of women during childbirth in facility settings that were identified in the later systematic review of mistreatment of women during facility-based childbirth by Bohren et al. [9].

Two reviewers (JS and RRJ) performed a head-to-head comparison of the rights identified in the two frame-works to compile a list of unique categories of the rights of women during pregnancy and childbirth. Using the synthesized categories of RMC from these two frame-works, we initiated a systematic review to operationalize the RMC categories through the description and cata-loguing of actionable elements and observable behaviors for each category.

Operational definition of respectful maternity careFour reviewers (RRJ, JG, NK, and KEAS) then system-atically reviewed peer-reviewed literature, grey literature, white papers and seminal documents on setting RMC standards to identify an operational definition of RMC at provider-level and its key elements within those previ-ously established seven rights-based categories of RMC.


Following the PRISMA methodology [28], we searched electronic databases of peer-reviewed articles (Medline [via PubMed]). We conducted a Google Scholar search for grey literature and white papers. We also searched the Columbia University Mailman School of Public Health Averting Maternal Death and Disability (AMDD) pro-gram’s monthly RMC literature and media summaries from 2017 to 2020, which capture published reports from non-governmental organizations, international organiza-tions, or ministries of health, as well as the World Health Organization website for content related to RMC. Addi-tionally, we hand-searched bibliographies of relevant articles to ensure that key documents with RMC con-tent are represented. All articles identified from different sources were imported into EndNote.

Our search string (limited to humans) was: (((((mistreatment[All Fields] AND ("women"[MeSH Terms] OR "women"[All Fields]) AND ("parturition"[MeSH Terms] OR "parturition"[All Fields] OR "childbirth"[All Fields])) OR "disrespect and abuse"[All Fields]) OR (dehumanized[All Fields] AND care[All Fields])) OR (humanized[All Fields] AND care[All Fields])) OR "obstetric violence"[All Fields]) OR "respectful maternity care"[All Fields] AND ((("pregnancy"[MeSH Terms] OR "pregnancy"[All Fields]) OR ("parturition"[MeSH Terms] OR "parturition"[All Fields] OR "childbirth"[All Fields])) OR maternity[All Fields]).

A PubMed search that was conducted using this string, with no start date and an end date of May 31, 2020, yielded 466 unique records. An additional 48 relevant articles were identified from supplemental hand searches as described. Forty-seven duplicates were removed. Thus, 467 articles were screened.

Two reviewers (NK and RRJ) screened titles and abstracts of all citations and two reviewers (JG and NK) reviewed the grey literature retrieved through hand search and the AMDD summaries. Articles were excluded if: (1) they lacked operationalized descriptions of RMC-related behaviors at the provider level; (2) they described the categories of mistreatment experienced by women during childbirth rather than respectful care behaviors in the affirmative; (3) they were not published in English or did not include an English translation; (4) they did not address facility-based childbirth. No exclu-sions were made on the basis of study design or study quality. The number of records excluded (along with the reason for exclusion) was documented. The full text of potentially eligible articles were independently reviewed by two reviewers (NK, RRJ or KEAS). Any discordance between two reviewers during both title and abstract screening and full-text review was resolved through dis-cussion among all three reviewers.

Data for qualitative synthesis were extracted from the final list of articles by two independent reviewers (RRJ and KEAS) using a standardized form developed based on the categories of RMC previously defined. From each article, the examples and descriptions of behaviors that providers can/should adopt to exemplify respectful care were identified and extracted. These data were combined, discussed, and synthesized to operationalize each cat-egory of RMC.

ResultsFrameworks defining rights of women during childbirthThe head-to-head comparison of the two frameworks utilized to summarize the rights of women during child-birth [20, 23] displayed significant overlap, with varia-tion in the level of detail provided (Table 1). When the two frameworks were compared, seven key categories of RMC during childbirth emerged. The seven key cat-egories focused on (1) right to be free from harm and ill treatment; (2) right to dignity and respect; (3) right to information, informed consent, respect for choices and preferences, including the right to companionship of choice where ever possible; (4) right to privacy and con-fidentiality; (5) right to non-discrimination, equality and equitable care; (6) right to timely healthcare and to the highest attainable level of health; and (7) right to liberty, autonomy, self-determination and freedom from coer-cion. Two domains identified in the framework by Khosla et al. were omitted from our analysis because they were not a provider-level obligation (right to an effective rem-edy) or not directly applicable during childbirth (right to decide the number, spacing, and timing of children).

Operational definition of respectful maternity careA total of 466 peer-reviewed articles were retrieved through electronic database search (Medline [via Pub-Med]) conducted on August 19, 2020. An additional 48 records were identified through Google Scholar, the World Health Organization website, the AMDD monthly RMC summaries from 2017 to 2020, and hand search-ing of bibliographies of relevant articles. After remov-ing duplicates, we screened titles and abstracts of 467 records. At this stage, 307 records were excluded as irrelevant because they did not have an explicit men-tion of RMC related content. We reviewed full-text of 160 records, of which 106 were excluded for the follow-ing reasons: they did not operationalize RMC (n = 56); they focused solely on disrespect and abuse (n = 29); they were not in English (n = 18); or they focused on preg-nancy care only and did not include facility-based child-birth (n = 3). The remaining 54 studies were selected for data extraction and qualitative evidence synthesis (Fig. 1).


From the themes identified across the two key frame-works, we documented the operationalized elements of RMC during childbirth from the 54 articles to each of the seven themes (Table 2). Most operational defini-tions focused on the relationship and care provided by clinicians to the woman and her newborn(s). However, in most environments, maternity care involves a team; thus, some themes extended the operational definitions of RMC to encompass interactions between providers. Here, we present each theme and their associated opera-tionalized approaches.

RMC I: Right to be free from harm and ill treatment. Forty-one of the 54 articles provided guidance on how providers can ensure a woman’s right to be free from harm, including violence, torture, harmful practices and ill treatment (physical, sexual and verbal abuse). The five behaviors that providers can perform under this theme focused on provision of appropriate care and avoidance of inappropriate practices. Providers should: (1) pro-vide only medically-indicated, evidence-based interven-tions; (2) avoid harmful practices including, overuse of interventions, drugs, and technology, and unnecessary separation of the mother and baby; (3) protect clients from individual and institutional violence and mistreat-ment, including physical, sexual, and verbal abuse. Cli-nicians should provide (4) food and fluids to women in normal labor and encouragement for early breastfeeding, including skin-to-skin contact with baby, immediately

postpartum, as well as (5) pharmacological and non-pharmacological pain relief options and supportive care.

RMC II: Right to dignity & respect. Forty-nine out of 54 articles described behaviors to uphold the right to dignity and respect within the context of facility-based childbirth, including the importance of respect within inter-provider relationships. Important areas of RMC operationalization in this category focused on: (1) provi-sion of culturally competent care, including respect for beliefs, traditions and culture; (2) respectful treatment of all clients, including respect for clients’ personhood, experiences, and feelings; and (3) respectful treatment of other clinicians and all other cadres of collaborating providers and staff. Further, providers should commu-nicate effectively (4) by using language that clients can understand, and that is respectful and polite; greeting and addressing clients politely and by name; and provid-ing verbal support and encouragement. Positive, support-ive non-verbal communication to clients (5) is another important behavior exemplifying the right to dignity and respect. Finally, respect and dignity are demonstrated through sensitivity and empathy for women and partners experiencing loss and bereavement (6).

RMC III: Right to information, informed consent and refusal, and respect for choices and preferences. Forty-nine out of 54 in the systematic review highlighted the importance of ensuring women are provided information and the opportunity to give informed consent or refusal,

Table 1 Head-to-head (direct) comparison of two frameworks defining rights of women during childbirth

Categories of Respectful Care during Childbirth Identified

White ribbon alliance [20]: Respectful Maternity Care: The Universal Rights of Childbearing Women (White Ribbon Alliance)

Khosla et al. [23]: International Human Rights and the Mistreatment of Women during Childbirth (World Health Organization)

RMC I. Right to be free from harm (violence, torture, harmful practices) and ill treatment (physical, sexual and verbal abuse)

Freedom from harm and ill treatment Right to be free from violence

Right to be free from torture and other ill-treatment

Right to be free from practices that harm women and girls

RMC II. Right to dignity and respect Dignity, respect

RMC III. Right to information, informed consent and refusal, and respect for choices and prefer-ences, including the right to companionship of choice wherever possible

Right to information, informed consent and refusal, and respect for choices and preferences, including the right to companionship of choice wherever possible

Right to information

RMC IV. Right to privacy and confidentiality Confidentiality, privacy Right to privacy

RMC V. Right to non-discrimination, equality and equitable care

Equality, freedom from discrimination, equitable care

Right to non-discrimination

RMC VI. Right to timely healthcare and to the highest attainable level of health

Right to timely healthcare and to the highest attainable level of health

Right to health

RMC VII. Right to liberty, autonomy, self-determi-nation, and freedom from coercion

Liberty, autonomy, self-determination, and freedom from coercion

Excluded: not a provider-level obligation Right to an effective remedy

Excluded: not during childbirth Right to decide the number, spacing and timing of children


and have their choices/decisions respected. Reflect-ing this right, operationally, (1) providers can encour-age and support women to move freely during labor and birth and assume the position of their choice; and, (2) present women with the option to experience labor and birth with the companion of their choice and to involve their significant others in their care and decisions if they desire. Further, respecting the right to information extends beyond clinical or health information to encom-pass information about the cost of care. Clinicians should (3) provide information to women about their care

options, what to expect during labor, birth and the post-partum period; information on proposed interventions, tests, and treatments; and any out-of-pocket costs. As part of enabling of the right to information and choice, clinicians should (4) provide honest and complete infor-mation, encourage women to ask questions and express their concerns and opinions, as well as (5) engage women with decision making about their care, solicit consent for all interventions, and respect their choices including refusal of interventions.

Fig. 1 Flow diagram showing the study selection process to identify an operational definition of respectful maternity care for frontline healthcare providers, 1980-May 2020


Tabl

e 2

Ope

ratio

naliz

atio

n of

cat

egor

ies

of re

spec

tful

car

e du

ring

child

birt

h, fo

r fro

ntlin

e he

alth

care

wor

kers

pro

vidi

ng m

ater

nity

car

e

Cate

gori

es o

f res

pect

ful c

are

duri

ng c

hild

birt

hO

pera

tiona

lizat

ion

of th

e ca

tego

ries

of r

espe

ctfu

l car

e du

ring

ch

ildbi

rth

Refe

renc

es

Righ

t to

be fr

ee fr

om h

arm

(vio

lenc

e, to

rtur

e, h

arm

ful p

ract

ices

) and

ill

trea

tmen

t (ph

ysic

al, s

exua

l and

ver

bal a

buse

)1.

Doc

tors

/nur

ses/

mid

wiv

es p

rovi

de o

nly

med

ical

ly-in

dica

ted,

evi

denc

e-ba

sed

inte

rven

tions

2. D

octo

rs/n

urse

s/m

idw

ives

avo

id h

arm

ful p

ract

ices

, inc

ludi

ng:

a. O

veru

se o

f int

erve

ntio

ns, d

rugs

and

tech

nolo

gy,

b. U

nnec

essa

ry s

epar

atio

n of

mot

her a

nd b

aby

3. D

octo

rs/n

urse

s/m

idw

ives

pro

tect

thei

r clie

nts

from

indi

vidu

al a

nd

inst

itutio

nal v

iole

nce

so th

at n

o cl

ient

is s

ubje

cted

to a

buse

or m

istr

eat-

men

t, in

clud

ing:

a. p

hysi

cal,

b. s

exua

l, or

c. v

erba

l4.

Doc

tors

/nur

ses/

mid

wiv

es p

rovi

de:

a. F

ood

and

fluid

s to

wom

en in

nor

mal

labo

rb.

Enc

oura

gem

ent f

or e

arly

bre

astfe

edin

g, in

clud

ing

skin

-to-

skin

con

tact

w

ith b

aby,

imm

edia

tely

pos

tpar

tum

5. D

octo

rs/n

urse

s/m

idw

ives

pro

vide

to w

omen

in la

bor a

nd b

irth

(to

stre

ngth

en th

eir c

apab

ilitie

s):

a. P

harm

acol

ogic

al a

ndb.

Non

-pha

rmac

olog

ical

pai

n re

lief o

ptio

ns a

nd s

uppo

rtiv

e ca

re

Reis

et a

l. [3

6];

Inte

rnat

iona

l Fed

erat

ion

of G

ynec

olog

y an

d O

bste

tric

s an

d ot

hers

. [27

];Ro

sen

et a

l. [3

7];

Thom

pson

et a

l. [3

8];

War

ren

[15]

;M

iller

et a

l. [3

9];

Shef

eraw

et a

l. [4

0];

Shef

eraw

[41]

;W

orld

Hea

lth O

rgan

izat

ion

[22]

; Kuj

awsk

i [42

];O

osth

uize

n [4

3];

Ase

fa [4

4];

Bohr

en [4

5];

Dyn

es [4

6];

Shak

ibaz

adeh

[47]

;Ta

avon

i [48

]; W

assi

hun

[49]

;W

orld

Hea

lth O

rgan

izat

ion

[50]

;A

fula

ni [5

1, 5

2];

Gio

rdan

o [5

3];

Oliv

eira

[54]

;Pe

rkin

s [5

5];

Afu

lani

[56]

;Ba

nte

[57]

;Bo

hren

[58]

;Bu

tler [

59];

Loth

ian

[24]

;M

onto

ya [6

0];

Mor

idi [

61];

Dev

ries

[62]

Page

[63]

Wag

ner [

64]

Gar

ciad

eLim

aPar

ada

[65]

Behr

uzi [

66]

Behr

uzi [

67]

Behr

uzi [

68]

Binf

a [6

9]O

uedr

aogo

[70]

Cone

saFe

rrer

[71]

Binf

a [7

2]


Tabl

e 2

(con

tinue

d)

Cate

gori

es o

f res

pect

ful c

are

duri

ng c

hild

birt

hO

pera

tiona

lizat

ion

of th

e ca

tego

ries

of r

espe

ctfu

l car

e du

ring

ch

ildbi

rth

Refe

renc

es

Righ

t to

dign

ity a

nd re

spec

t1.

Doc

tors

/nur

ses/

mid

wiv

es p

rovi

de c

ultu

rally

com

pete

nt c

are,

incl

udin

g re

spec

t for

bel

iefs

, tra

ditio

ns a

nd c

ultu

re2.

Doc

tors

/nur

ses/

mid

wiv

es tr

eat e

very

clie

nt w

ith re

spec

t, in

clud

ing

resp

ect f

or th

eir p

erso

nhoo

d, e

xper

ienc

es, a

nd fe

elin

gs3.

Doc

tors

/nur

ses/

mid

wiv

es tr

eat e

ach

othe

r and

all

othe

r cad

res

of c

ol-

labo

ratin

g pr

ovid

ers

and

staff

with

resp

ect

4. D

octo

rs/n

urse

s/m

idw

ives

com

mun

icat

e eff

ectiv

ely

with

clie

nts,

by:

a. U

sing

lang

uage

that

is re

spec

tful

and

pos

itive

,b.

Usi

ng la

ngua

ge th

ey c

an u

nder

stan

d,c.

Gre

etin

g an

d ad

dres

sing

wom

en p

olite

ly a

nd b

y na

me,

and

d. P

rovi

ding

ver

bal s

uppo

rt a

nd e

ncou

rage

men

t5.

Doc

tors

/nur

ses/

mid

wiv

es p

rovi

de p

ositi

ve, s

uppo

rtiv

e no

n-ve

rbal

com

-m

unic

atio

n to

clie

nts

6. D

octo

rs/n

urse

s/m

idw

ives

dem

onst

rate

sen

sitiv

ity a

nd e

mpa

thy

for

wom

en a

nd p

artn

ers

expe

rienc

ing

loss

and

ber

eave

men

t

Reis

et a

l. [3

6];

War

ren

et a

l. [7

3];

Inte

rnat

iona

l Fed

erat

ion

of G

ynec

olog

y an

d O

bste

tric

s an

d ot

hers

. [27

];Ro

sen

et a

l. [3

7];

Thom

pson

et a

l. [3

8];

War

ren

[15]

;M

iller

et a

l. [3

9];

Pate

l et a

l. [7

4];

Shef

eraw

et a

l. [4

0];

Soln

es e

t al.

[75]

;W

orld

Hea

lth O

rgan

izat

ion

[22]

;Ka

mba

la [7

6];

Kuja

wsk

i [42

];N

dwig

a [7

7];

Oos

thui

zen

[43]

;Sh

efer

aw [4

1];

Veda

m e

t al.

[78]

,Ve

dam

et a

l. [7

9];

Ase

fa [4

4];

Bohr

en [4

5];

Dyn

es [4

6];

Shak

ibaz

adeh

[47]

;Ta

avon

i [48

];W

assi

hun

[49]

;W

orld

Hea

lth O

rgan

izat

ion

[50]

;A

fula

ni [5

1, 5

2, 8

0];

Feije

n-de

Jong

[81]

;G

iord

ano

[53]

;O

livei

ra [5

4];

Afu

lani

[56]

;A

youb

i [82

];Ba

nte

[57]

;Bo

hren

[58]

;Bu

tler [

59];

Loth

ian

[24]

;M

orid

i [61

];M

onto

ya [6

0];

Page

[63]

Jorg

e [8

3]G

uim

arae

s [8

4]Be

hruz

i [66

][6

8] B

ehru

zi 2

011

Binf

a [6

9]O

uedr

aogo

[70]

Cone

saFe

rrer

[71]

Binf

a [7

2]Lo

kuga

mag

e [8

5]


Tabl

e 2

(con

tinue

d)

Cate

gori

es o

f res

pect

ful c

are

duri

ng c

hild

birt

hO

pera

tiona

lizat

ion

of th

e ca

tego

ries

of r

espe

ctfu

l car

e du

ring

ch

ildbi

rth

Refe

renc

es

Righ

t to

info

rmat

ion,

info

rmed

con

sent

and

refu

sal,

and

resp

ect f

or

choi

ces

and

pref

eren

ces,

incl

udin

g th

e rig

ht to

com

pani

onsh

ip o

f cho

ice

whe

reve

r pos

sibl

e

1. D

octo

rs/n

urse

s/m

idw

ives

enc

oura

ge a

nd s

uppo

rt w

omen

to:

a. M

ove

freel

y du

ring

labo

r and

b. A

ssum

e th

e po

sitio

n of

thei

r cho

ice

for b

irth

2. D

octo

rs/n

urse

s/m

idw

ives

offe

r wom

en th

e op

tion

to e

xper

ienc

e la

bor

and

birt

h w

ith th

e co

mpa

nion

of t

heir

choi

ce a

nd in

volv

e th

eir f

amily

m

embe

rs in

car

e an

d de

cisi

ons

if de

sire

d3.

Doc

tors

/nur

ses/

mid

wiv

es p

rovi

de in

form

atio

n to

clie

nts

abou

t the

ir he

alth

and

car

e op

tions

, inc

ludi

ng:

a. W

hat t

o ex

pect

dur

ing

labo

r and

birt

h,, p

ostp

artu

m a

nd n

ewbo

rn c

are

b. In

form

atio

n on

pro

pose

d in

terv

entio

ns, t

ests

and

trea

tmen

ts, a

ndc.

Any

out

-of-p

ocke

t cos

ts o

f car

e to

be

prov

ided

4. D

octo

rs/n

urse

s/m

idw

ives

enc

oura

ge c

lient

s to

:a.

Ask

que

stio

ns a

ndb.

Exp

ress

opi

nion

s or

con

cern

s5.

Doc

tors

/nur

ses/

mid

wiv

es:

a. P

rovi

de h

ones

t and

com

plet

e in

form

atio

n,b

.Invo

lve

clie

nts

in d

ecis

ion

mak

ing

abou

t the

ir ca

re,

c. S

olic

it co

nsen

t for

all

inte

rven

tions

, and

d. R

espe

ct c

hoic

es in

clud

ing

refu

sal o

f int

erve

ntio

ns

Reis

et a

l. [3

6];

War

ren

et a

l. [7

3];

Inte

rnat

iona

l Fed

erat

ion

of G

ynec

olog

y an

d O

bste

tric

s an

d ot

hers

. [27

];Ro

sen

et a

l. [3

7]; T

hom

pson

et a

l. [3

8];

War

ren

[15]

;M

iller

et a

l. [3

9];

Pate

l et a

l. [7

4];

Shef

eraw

et a

l. [4

0];

Soln

es e

t al.

[75]

;W

orld

Hea

lth O

rgan

izat

ion

[22]

;Ka

mba

la [7

6];

Kuja

wsk

i [42

];N

dwig

a [7

7];

Oos

thui

zen

[43]

;Sh

efer

aw [4

1];

Veda

m e

t al.

[78,

79]

;A

sefa

[44]

;Bo

hren

[45]

;D

ynes

[46]

;Sh

akib

azad

eh [4

7];

Taav

oni [

48];

Wor

ld H

ealth

Org

aniz

atio

n [5

0];

Afu

lani

[51,

52,

80]

;Fe

ijen-

deJo

ng [8

1];

Gio

rdan

o [5

3];

Perk

ins

[55]

; Afu

lani

[56]

;A

youb

i [82

];Bo

hren

[58]

;Bu

tler [

59];

Loth

ian

[24]

;M

orid

i [61

];M

onto

ya [6

0];

Page

[63]

Wag

ner [

64]

Gui

mar

aes

[84]

Gar

ciad

eLim

aPar

ada

[65]

Behr

uzi [

66, 6

7]Be

hruz

i [68

]Bi

nfa

[69]

Oue

drao

go [7

0]Co

nesa

Ferr

er [7

1]Bi

nfa

[72]

Loku

gam

age

[85]


Tabl

e 2

(con

tinue

d)

Cate

gori

es o

f res

pect

ful c

are

duri

ng c

hild

birt

hO

pera

tiona

lizat

ion

of th

e ca

tego

ries

of r

espe

ctfu

l car

e du

ring

ch

ildbi

rth

Refe

renc

es

Righ

t to

priv

acy

and

confi

dent

ialit

y1.

Doc

tors

/nur

ses/

mid

wiv

es p

rovi

de v

isua

l and

aud

itory

priv

acy

to c

lient

s du

ring

labo

r and

birt

h, e

.g.,

by p

rovi

ding

car

e in

a p

rivat

e ro

om, o

r usi

ng

curt

ains

, scr

eens

, or d

rape

s, an

d lim

iting

the

peop

le p

rese

nt to

thos

e cl

ini-

cally

indi

cate

d or

des

ired

by th

e w

oman

2. D

octo

rs/n

urse

s/m

idw

ives

kee

p pa

tient

info

rmat

ion

confi

dent

ial a

nd

do n

ot s

hare

pat

ient

info

rmat

ion

unle

ss in

dica

ted

for t

he p

rovi

sion

of

effec

tive

care

War

ren

et a

l. [7

3];

Inte

rnat

iona

l Fed

erat

ion

of G

ynec

olog

y an

d O

bste

tric

s an

d ot

hers

. [27

];Ro

sen

et a

l. [3

7];

Thom

pson

et a

l. [3

8];

Mill

er e

t al.

[39]

;Pa

tel e

t al.

[74]

;So

lnes

et a

l. [7

5];

Wor

ld H

ealth

Org

aniz

atio

n [2

2];

Kam

bala

[76]

;Ku

jaw

ski [

42];

Ndw

iga

[77]

;Ve

dam

et a

l. [7

8, 7

9];

Ase

fa [4

4];

Bohr

en [4

5];

Dyn

es [4

6];

Shak

ibaz

adeh

[47]

;Ta

avon

i [48

];W

orld

Hea

lth O

rgan

izat

ion

[50]

;A

fula

ni [5

1, 5

2, 8

0];

Gio

rdan

o [5

3];

Afu

lani

[56]

;[8

2] A

youb

i 202

0;[2

4, 5

9–61

] But

ler;

Loth

ian;

Mor

idi;

Mon

toya

;Be

hruz

i [67

]O

uedr

aogo

[70]

Cone

saFe

rrer

[71]

Righ

t to

non-

disc

rimin

atio

n, e

qual

ity a

nd e

quita

ble

care

1. D

octo

rs/n

urse

s/m

idw

ives

adh

ere

to p

olic

ies

on n

on-d

iscr

imin

atio

n2.

Doc

tors

/nur

ses/

mid

wiv

es tr

eat e

very

clie

nt w

ith e

qual

resp

ect a

nd

dign

ity, r

egar

dles

s of

any

spe

cific

per

sona

l att

ribut

es, i

nclu

ding

but

no

t lim

ited:

to a

ge, w

ealth

, cla

ss, e

duca

tion,

race

or e

thni

city

, rel

igio

n,

LGBT

Q+

, HIV

or o

ther

hea

lth s

tatu

s

War

ren

et a

l. [1

5, 7

3]In

tern

atio

nal F

eder

atio

n of

Gyn

ecol

ogy

and

Obs

tetr

ics

and

othe

rs. [

27];

Soln

es e

t al.

[75]

;W

orld

Hea

lth O

rgan

izat

ion

[22]

;Ve

dam

et a

l. [7

9]Sh

akib

azad

eh [4

7];

Afu

lani

; Ayo

ubi;

Bohr

en; B

utle

r; Lo

thia

n [2

4, 5

6, 5

8, 5

9, 8

2]M

orid

i [61

]


Tabl

e 2

(con

tinue

d)

Cate

gori

es o

f res

pect

ful c

are

duri

ng c

hild

birt

hO

pera

tiona

lizat

ion

of th

e ca

tego

ries

of r

espe

ctfu

l car

e du

ring

ch

ildbi

rth

Refe

renc

es

Righ

t to

timel

y he

alth

care

and

to th

e hi

ghes

t att

aina

ble

leve

l of h

ealth

1. D

octo

rs/n

urse

s/m

idw

ives

pro

vide

pro

mpt

att

entio

n an

d ar

e re

spon

sive

to

clie

nts’

need

s fo

r:a.

Med

ical

car

e an

db.

Com

fort

car

e2.

Doc

tors

/nur

ses/

mid

wiv

es e

nsur

e th

at e

very

wom

an h

as a

ski

lled

atte

n-da

nt p

rese

nt a

t her

birt

h3.

Doc

tors

/nur

ses/

mid

wiv

es e

nsur

e th

at n

o cl

ient

is n

egle

cted

or d

enie

d ne

eded

car

e, re

gard

less

of a

bilit

y to

pay

4. D

octo

rs/n

urse

s/m

idw

ives

ens

ure

cont

inui

ty o

f car

e by

coo

rdin

atin

g eff

ectiv

ely

acro

ss s

ettin

gs a

nd b

etw

een

prov

ider

s

Reis

et a

l. [3

6];

War

ren

et a

l. [1

5, 7

3]In

tern

atio

nal F

eder

atio

n of

Gyn

ecol

ogy

and

Obs

tetr

ics

and

othe

rs. [

27];

Shef

eraw

et a

l. [4

0];

Soln

es e

t al.

[75]

;Ka

mba

la; K

ujaw

ski;

Ndw

iga,

Oos

thui

zen

[42,

43,

76,

77]

;A

sefa

; Boh

ren;

Dyn

es; S

haki

baza

deh;

Taa

voni

; Was

sihu

n; W

orld

Hea

lth

Org

aniz

atio

n [4

4–50

];A

fula

ni; A

fula

ni; A

youb

i; Ba

nte;

But

ler;

Loth

ian;

Mor

idi;

[24,

52,

56,

57,

59,

61,

80

, 82]

Behr

uzi [

68]

Oue

drao

go [7

0]Bi

nfa

[72]

Righ

t to

liber

ty, a

uton

omy,

sel

f-de

term

inat

ion,

and

free

dom

from

coe

rcio

n1.

Doc

tors

/nur

ses/

mid

wiv

es d

o no

t ille

gally

det

ain

or p

hysi

cally

rest

rain

cl

ient

s in

the

faci

lity

for a

ny re

ason

, inc

ludi

ng in

abili

ty to

pay

2. D

octo

rs/n

urse

s/m

idw

ives

do

not p

reve

nt c

lient

s fro

m s

eein

g or

hol

ding

th

eir b

abie

s fo

r any

reas

on, i

nclu

ding

inab

ility

to p

ay

Reis

et a

l. [3

6];

Inte

rnat

iona

l Fed

erat

ion

of G

ynec

olog

y an

d O

bste

tric

s an

d ot

hers

. [27

];W

orld

Hea

lth O

rgan

izat

ion

[22]

;N

dwig

a [7

7]Ta

avon

i [48

];A

fula

ni [5

6];

Loth

ian

[24]

;


RMC IV: Right to privacy and confidentiality. A narrow majority of articles (32 out of 54) included reference to the importance of the right to (1) privacy and (2) confi-dentiality. Providers should keep patient information confidential and not share information unless indicated for the provision of effective care. In the synthesis, pri-vacy and confidentiality were operationalized beyond sharing details of a medical record. Operationalizing the right to privacy and confidentiality focused on providing visual and auditory privacy to clients, including the use of drapes, screens, private room, etc., as well as limiting the number of people present to those clinically indicated or desired by the woman.

RMC V: Right to non-discrimination, equality and equi-table care. Far fewer articles, thirteen out of 54 records, identified the importance of non-discrimination, equal-ity and equitable care that were focused on (1) adhering to policies on non-discrimination. Further, providers should (2) treat every client with equal respect and dig-nity, regardless of specific personal attributes including, but not limited to age, wealth, class, education, race or ethnicity, religion, LGBTQI + , and health or HIV status.

RMC VI: Right to timely healthcare and to the highest attainable level of health. Twenty-eight records out of 54 noted the right to timely healthcare that focused on providers (1) giving prompt attention and being respon-sive to clients’ needs for medical care and comfort care. A critical component to operationalizing this right is (2) ensuring that every woman has a skilled birth atten-dant present at birth. Additionally, providers should (3) guarantee that no client is neglected or denied necessary care based on ability of pay. Finally, providers should (4) ensure continuity of care by coordinating across facili-ties/sites or settings and between providers.

RMC VII: Right to liberty, autonomy, self-determination and freedom from coercion. Only seven articles out of 54 focused on the right to liberty and self-determination. Two key operationalized actions emerged. Providers should not illegally detain or physically restrain women or their families in the facility for any reason, including inability to pay. Second, women should never be pre-vented from holding, seeing, or being with their newborn for any reason, including inability to pay.

DiscussionRMC is a human right and a widely recognized core com-ponent of quality care [5, 20, 23]. Although articulation of the right to RMC is aligned around seven key rights principles, the operationalization of each principle within the context of healthcare professional behavior has been limited and disjointed. Grounded in two seminal rights-based documents defining the critical categories of RMC and using a systematic review of peer-reviewed and grey

literature, we propose actionable practices and behav-iors to operationalize RMC for maternity care providers. Global standard setting, professional guideline develop-ment, and program implementation can be clarified with this consolidated, evidence-informed set of key functions to enable and empower RMC by providers and clinicians.

In the systematic review, 54 articles were identified that described objective behaviors or concrete guidance and steps to meet the seven key principles of RMC. However, most of the articles provided insights on behaviors aimed at enacting three out of the seven key principles: (1) the right to be free from harm and ill treatment; (2) the right to dignity and respect; (3) the right to information, informed consent and refusal, and respect for choices and preferences. Fewer than two-thirds of articles refer-enced behaviors reflecting the right to privacy and confi-dentiality, although lack of privacy has been found to be a barrier to facility care across numerous studies [18]. Fur-thermore, only roughly half of articles reflected actions to uphold the right to timely healthcare and to the highest attainable level of health. Given the attention to increas-ing skilled birth attendance globally [29], it is surprising that more articles focused on RMC did not emphasize the right to timely care and attendance during birth. Moreover, less than a quarter of the articles reviewed specified provider behaviors aimed at ensuring the right to non-discrimination, equality and equitable care. Given the salience of health disparities in maternity care in terms of coverage of key interventions, quality of care, experiences of care, and outcomes of care, both within and across countries, this finding has important impli-cations and emphasizes the need for more attention to operationalizing RMC in this area [30–33]. In addition, less than 15% of articles reviewed reflected the right to liberty, bodily autonomy, self-determination and freedom from coercion. The egregiousness of the harm caused to women, infants, and families from detention in childbirth facilities and evidence that suggests such behavior can be driven by individual, ad hoc judgments at provider and staff level in weak facilities [34] warrants provider-level accountability as duty-bearers to uphold and fulfill this right. The lack of available literature that included opera-tionalized definitions corresponding to these two catego-ries of RMC illustrates the nascent stage of evidence in this area.

There are some key strengths and limitations to this analysis. To our knowledge, this is the first systematic review of provider behaviors constituting RMC; further-more, it rests on a firm conceptual foundation provided by two highly convergent definitional frameworks enumerat-ing key RMC principles [20, 23]. An additional strength is the consistency of the operational definitions identi-fied. Over the course of the development of the review,


numerous new articles were released that discuss RMC, reflecting growing interest and ongoing efforts in this area; nevertheless, the foundational principles of RMC have not been altered. Not surprisingly, given the greater emphasis on health facility deficiencies in the influential 2015 sys-tematic review by Bohren et al. [9], a notable addition to the seven essential elements of RMC in more recent lit-erature is the evaluation of health system and facility char-acteristics. The addition of this new dimension did not change our operational definitions of RMC for the purpose of this review, given our focus on provider-level behaviors. One potential limitation, as with any systematic review, is that some relevant literature may not have been captured if our search terms were not comprehensive, and because of the exclusion of non-English articles. To address this limi-tation at least partly our search strategy included a system-atic search of databases, a bibliographic search, and review of the grey literature. Of the 106 full-text articles reviewed and excluded, only 18 were excluded because no English translation was available.

Implications for practiceIn proposing a codification of actionable and operational definitions for the fundamental principles of RMC based on evidence, this qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, and program evaluation aimed at studying and improving RMC at the provider level. Across diverse settings, context-specific interpretations and expressions of these provider-level behaviors may be needed to fully operationalize RMC II: the right to dig-nity and respect, particularly, in its aspect related to the provision of culturally competent care, including respect for beliefs, traditions and culture.

Implications for researchFor the research community, these operational functions and definitions of RMC can provide a launching point for validation as well as a common lexicon and basis for measurement and assessment of RMC. Currently, assess-ment of RMC has been approached using varied defini-tions and methods, including observation of childbirth and post-childbirth interviews with women. Potentially, this list of functional RMC actions broadens the scope for assessment and provides practical care steps to be monitored. Further, indicators built around these opera-tionalized definitions can contribute to the assessment of effective coverage of high quality childbirth care [35].

ConclusionsIt is hoped that this review and synthesis will contrib-ute toward an evidence-based foundation for provider level interventions to improve the delivery of respectful

maternity care. The systematic codification, grounded in evidence, of operational definitions for RMC at the pro-vider level should facilitate the study, design, implemen-tation, and comparative assessment of respectful care.

AbbreviationsAAAQ: Available, accessible, acceptable, quality; AMDD: Averting Maternal Death and Disability; RMC: Respectful Maternity Care.

AcknowledgementsNot applicable.

Authors’ contributionsRRJ conceptualized and designed the study; AL received funding for the study and contributed to the conceptualization. JS contributed to the study design and conducted the head-to-head comparison of RMC rights frameworks. NK conducted the literature search; RRJ, KEAS, NK, and JG abstracted the informa-tion and conducted the systematic review. RRJ and NK drafted manuscript outline. KEAS and RRJ drafted the manuscript; all authors reviewed, edited and agreed to the final manuscript. All authors read and approved the revised manuscript.

FundingThis study has been partially supported through John D. and Catherine T. MacArthur Foundation grant received by Dr. Ana Langer (Grant Number: #15-107912-000-INP) that ended 30 September 2017.

Availability of data and materialsThe data supporting the conclusions of this article are included within the article.

Declarations

Ethics approval and consent to participateThis systematic scoping review has been deemed non-human subjects research by the Institutional Review Board of Harvard T. H. Chan School of Public Health.

Consent for publicationAll authors have read the manuscript and have consented for publication.

Competing interestsThe authors have no competing interests to declare.

Author details1 Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. 2 BetterBirth Program, Ariadne Labs|Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA. 3 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA. 4 Department of Medicine, Harvard Medical School, 401 Park Drive, 3rd Floor West, Boston, MA 02215, USA.

Received: 31 March 2021 Accepted: 9 September 2021

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